Healthcare Provider Details

I. General information

NPI: 1568610996
Provider Name (Legal Business Name): ASHLEY CHISUM B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 W CERRITOS AVE
ANAHEIM CA
92805-6546
US

IV. Provider business mailing address

160 W CERRITOS AVE
ANAHEIM CA
92805-6546
US

V. Phone/Fax

Practice location:
  • Phone: 714-687-6710
  • Fax: 714-533-6884
Mailing address:
  • Phone: 714-687-6710
  • Fax: 714-533-6884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: